Initial Management of Noncastrate Advanced, Recurrent, or Metastatic Prostate Cancer: ASCO Guideline Update

Abstract

PURPOSE Update all preceding ASCO guidelines on initial hormonal management of noncastrate advanced, recurrent, or metastatic prostate cancer. METHODS The Expert Panel based recommendations on a systematic literature review. Recommendations were approved by the Expert Panel and the ASCO Clinical Practice Guidelines Committee. RESULTS Four clinical practice guidelines, one clinical practice guidelines endorsement, 19 systematic reviews with or without meta-analyses, 47 phase III randomized controlled trials, nine cohort studies, and two review papers informed the guideline update. RECOMMENDATIONS Docetaxel, abiraterone, enzalutamide, or apalutamide, each when administered with androgen deprivation therapy (ADT), represent four separate standards of care for noncastrate metastatic prostate cancer. Currently, the use of any of these agents in any particular combination or series cannot be recommended. ADT plus docetaxel, abiraterone, enzalutamide, or apalutamide should be offered to men with metastatic noncastrate prostate cancer, including those who received prior therapies, but have not yet progressed. The combination of ADT plus abiraterone and prednisolone should be considered for men with noncastrate locally advanced nonmetastatic prostate cancer who have undergone radiotherapy, rather than castration monotherapy. Immediate ADT may be offered to men who initially present with noncastrate locally advanced nonmetastatic disease who have not undergone previous local treatment and are unwilling or unable to undergo radiotherapy. Intermittent ADT may be offered to men with high-risk biochemically recurrent nonmetastatic prostate cancer. Active surveillance may be offered to men with low-risk biochemically recurrent nonmetastatic prostate cancer. The panel does not support use of either micronized abiraterone acetate or the 250 mg dose of abiraterone with a low-fat breakfast in the noncastrate setting at this time. Additional information is available at www.asco.org/genitourinary-cancer-guidelines .

Population-Based Study of Docetaxel or Abiraterone Effectiveness and Predictive Markers of Progression Free Survival in Metastatic Castration-Sensitive Prostate Cancer

“…Numerically, all of these interventions improved median overall survival (OS) in a clinically meaningful way compared to ADT alone with hazard ratios (HRs) between 0.61 and 0.88 (14). With the availability of such a broad therapeutic arsenal consisting of agents with different toxicity profiles, clinicians can choose the most suitable treatment option depending on associated comorbidities and burden as well as distribution of disease (15,16).…”

Novel Target Opportunities in Non-Metastatic Castrate Resistant Prostate Cancer

“…Much has been said about inhibiting STAT3 in cancer. STAT3 is an established target in the majority of advanced human tumors including prostate cancers [ 56 , 57 ]. STAT3 is elevated in prostate cancer cells as well as in many types of tumor-infiltrating immune cells, therefore pharmacological approaches aim to downregulate STAT3 function.…”

“…Incidence of these type of tumors is expected to rise upon increased use of novel anti-AR agents [ 29 , 58 , 59 ]. These tumors alike classical NEPC tumors [ 59 ] are likely to be challenging to treat as they are resistant to anti-AR agents and are usually treated with platinum therapy subsequent to exhausting taxane therapy [ 56 , 59 , 60 , 61 ].…”

Combined Longitudinal Clinical and Autopsy Phenomic Assessment in Lethal Metastatic Prostate Cancer: Recommendations for Advancing Precision Medicine

“…We also analyzed relevant literature-reported biomarker associations between clinical findings and features predicting disease trajectory. We combined these results to propose a framework for future data recording that encompasses both clinical observational studies and intervention trials in the context of recent advanced prostate cancer (PC) trial data recommendations [4] , [6] and guidelines [7] , [8] , [9] . Broader and better harmonized collection of phenotype data, with associated identification of best-performing biomarkers, will hasten progress toward improved outcomes.…”